White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ANCHOR SUTURE Y-KNOT RC W/NEEDLE ALL

Facility

$2,805.45

Service Code	HCPCS C1713
Hospital Charge Code	145479
Hospital Revenue Code	278
Min. Negotiated Rate	$701.36
Max. Negotiated Rate	$1,402.72
Rate for Payer: Aetna Commercial	$841.63
Rate for Payer: Cash Price	$2,468.80
Rate for Payer: Cigna Commercial	$701.36
Rate for Payer: Multiplan Auto	$1,402.72
Rate for Payer: Multiplan Commercial	$1,402.72
Rate for Payer: Multiplan Workers Comp	$1,402.72
Rate for Payer: Scott and White EPO/PPO	$1,402.72

ANCHOR SUTURE Y-KNOT YP1802

Facility

$4,744.28

Service Code	HCPCS C1713
Hospital Charge Code	145073
Hospital Revenue Code	278
Min. Negotiated Rate	$1,186.07
Max. Negotiated Rate	$2,372.14
Rate for Payer: Aetna Commercial	$1,423.28
Rate for Payer: Cash Price	$4,174.97
Rate for Payer: Cigna Commercial	$1,186.07
Rate for Payer: Multiplan Auto	$2,372.14
Rate for Payer: Multiplan Commercial	$2,372.14
Rate for Payer: Multiplan Workers Comp	$2,372.14
Rate for Payer: Scott and White EPO/PPO	$2,372.14

ANCHOR SUTURE Y-KNOT YP1802

Facility

$4,744.28

Service Code	HCPCS C1713
Hospital Charge Code	145073
Hospital Revenue Code	278
Min. Negotiated Rate	$426.99
Max. Negotiated Rate	$2,372.14
Rate for Payer: Aetna Commercial	$1,423.28
Rate for Payer: Amerigroup CHIP/Medicaid	$426.99
Rate for Payer: BCBS of TX Blue Advantage	$1,423.28
Rate for Payer: BCBS of TX Blue Essentials	$1,707.94
Rate for Payer: BCBS of TX PPO	$1,897.71
Rate for Payer: Cash Price	$4,174.97
Rate for Payer: Multiplan Auto	$2,372.14
Rate for Payer: Multiplan Commercial	$2,372.14
Rate for Payer: Multiplan Workers Comp	$2,372.14
Rate for Payer: Scott and White EPO/PPO	$2,372.14
Rate for Payer: Superior Health Plan EPO	$645.22

ANCHOR SUTURE Y-KNT YP1301B

Facility

$4,578.31

Service Code	HCPCS C1713
Hospital Charge Code	145072
Hospital Revenue Code	278
Min. Negotiated Rate	$412.05
Max. Negotiated Rate	$2,289.16
Rate for Payer: Aetna Commercial	$1,373.49
Rate for Payer: Amerigroup CHIP/Medicaid	$412.05
Rate for Payer: BCBS of TX Blue Advantage	$1,373.49
Rate for Payer: BCBS of TX Blue Essentials	$1,648.19
Rate for Payer: BCBS of TX PPO	$1,831.32
Rate for Payer: Cash Price	$4,028.91
Rate for Payer: Multiplan Auto	$2,289.16
Rate for Payer: Multiplan Commercial	$2,289.16
Rate for Payer: Multiplan Workers Comp	$2,289.16
Rate for Payer: Scott and White EPO/PPO	$2,289.16
Rate for Payer: Superior Health Plan EPO	$622.65

ANCHOR SUTURE Y-KNT YP1301B

Facility

$4,578.31

Service Code	HCPCS C1713
Hospital Charge Code	145072
Hospital Revenue Code	278
Min. Negotiated Rate	$1,144.58
Max. Negotiated Rate	$2,289.16
Rate for Payer: Aetna Commercial	$1,373.49
Rate for Payer: Cash Price	$4,028.91
Rate for Payer: Cigna Commercial	$1,144.58
Rate for Payer: Multiplan Auto	$2,289.16
Rate for Payer: Multiplan Commercial	$2,289.16
Rate for Payer: Multiplan Workers Comp	$2,289.16
Rate for Payer: Scott and White EPO/PPO	$2,289.16

ANCHOR THREVO W/ HI FI

Facility

$2,181.51

Service Code	HCPCS C1713
Hospital Charge Code	141588
Hospital Revenue Code	278
Min. Negotiated Rate	$196.34
Max. Negotiated Rate	$1,090.76
Rate for Payer: Aetna Commercial	$654.45
Rate for Payer: Amerigroup CHIP/Medicaid	$196.34
Rate for Payer: BCBS of TX Blue Advantage	$654.45
Rate for Payer: BCBS of TX Blue Essentials	$785.34
Rate for Payer: BCBS of TX PPO	$872.60
Rate for Payer: Cash Price	$1,919.73
Rate for Payer: Multiplan Auto	$1,090.76
Rate for Payer: Multiplan Commercial	$1,090.76
Rate for Payer: Multiplan Workers Comp	$1,090.76
Rate for Payer: Scott and White EPO/PPO	$1,090.76
Rate for Payer: Superior Health Plan EPO	$296.69

ANCHOR THREVO W/ HI FI

Facility

$2,181.51

Service Code	HCPCS C1713
Hospital Charge Code	141588
Hospital Revenue Code	278
Min. Negotiated Rate	$545.38
Max. Negotiated Rate	$1,090.76
Rate for Payer: Aetna Commercial	$654.45
Rate for Payer: Cash Price	$1,919.73
Rate for Payer: Cigna Commercial	$545.38
Rate for Payer: Multiplan Auto	$1,090.76
Rate for Payer: Multiplan Commercial	$1,090.76
Rate for Payer: Multiplan Workers Comp	$1,090.76
Rate for Payer: Scott and White EPO/PPO	$1,090.76

ANCHOR Y-KNOT PROFLEX W/ HIFI 1.3MM

Facility

$4,578.31

Service Code	HCPCS C1713
Hospital Charge Code	145180
Hospital Revenue Code	278
Min. Negotiated Rate	$1,144.58
Max. Negotiated Rate	$2,289.16
Rate for Payer: Aetna Commercial	$1,373.49
Rate for Payer: Cash Price	$4,028.91
Rate for Payer: Cigna Commercial	$1,144.58
Rate for Payer: Multiplan Auto	$2,289.16
Rate for Payer: Multiplan Commercial	$2,289.16
Rate for Payer: Multiplan Workers Comp	$2,289.16
Rate for Payer: Scott and White EPO/PPO	$2,289.16

ANCHOR Y-KNOT PROFLEX W/ HIFI 1.3MM

Facility

$4,578.31

Service Code	HCPCS C1713
Hospital Charge Code	145180
Hospital Revenue Code	278
Min. Negotiated Rate	$412.05
Max. Negotiated Rate	$2,289.16
Rate for Payer: Aetna Commercial	$1,373.49
Rate for Payer: Amerigroup CHIP/Medicaid	$412.05
Rate for Payer: BCBS of TX Blue Advantage	$1,373.49
Rate for Payer: BCBS of TX Blue Essentials	$1,648.19
Rate for Payer: BCBS of TX PPO	$1,831.32
Rate for Payer: Cash Price	$4,028.91
Rate for Payer: Multiplan Auto	$2,289.16
Rate for Payer: Multiplan Commercial	$2,289.16
Rate for Payer: Multiplan Workers Comp	$2,289.16
Rate for Payer: Scott and White EPO/PPO	$2,289.16
Rate for Payer: Superior Health Plan EPO	$622.65

ANCHOR Y-KNOT PROFLEX W/RIBBON 1.8MM

Facility

$5,574.10

Service Code	HCPCS C1713
Hospital Charge Code	145179
Hospital Revenue Code	278
Min. Negotiated Rate	$1,393.53
Max. Negotiated Rate	$2,787.05
Rate for Payer: Aetna Commercial	$1,672.23
Rate for Payer: Cash Price	$4,905.21
Rate for Payer: Cigna Commercial	$1,393.53
Rate for Payer: Multiplan Auto	$2,787.05
Rate for Payer: Multiplan Commercial	$2,787.05
Rate for Payer: Multiplan Workers Comp	$2,787.05
Rate for Payer: Scott and White EPO/PPO	$2,787.05

ANCHOR Y-KNOT PROFLEX W/RIBBON 1.8MM

Facility

$5,574.10

Service Code	HCPCS C1713
Hospital Charge Code	145179
Hospital Revenue Code	278
Min. Negotiated Rate	$501.67
Max. Negotiated Rate	$2,787.05
Rate for Payer: Aetna Commercial	$1,672.23
Rate for Payer: Amerigroup CHIP/Medicaid	$501.67
Rate for Payer: BCBS of TX Blue Advantage	$1,672.23
Rate for Payer: BCBS of TX Blue Essentials	$2,006.68
Rate for Payer: BCBS of TX PPO	$2,229.64
Rate for Payer: Cash Price	$4,905.21
Rate for Payer: Multiplan Auto	$2,787.05
Rate for Payer: Multiplan Commercial	$2,787.05
Rate for Payer: Multiplan Workers Comp	$2,787.05
Rate for Payer: Scott and White EPO/PPO	$2,787.05
Rate for Payer: Superior Health Plan EPO	$758.08

ANCH SUT ALLTHREAD -- DHF

Facility

$821.14

Service Code	HCPCS C1713
Hospital Charge Code	40106999
Hospital Revenue Code	278
Min. Negotiated Rate	$205.28
Max. Negotiated Rate	$410.57
Rate for Payer: Aetna Commercial	$246.34
Rate for Payer: Cash Price	$722.60
Rate for Payer: Cigna Commercial	$205.28
Rate for Payer: Multiplan Auto	$410.57
Rate for Payer: Multiplan Commercial	$410.57
Rate for Payer: Multiplan Workers Comp	$410.57
Rate for Payer: Scott and White EPO/PPO	$410.57

ANCH SUT ALLTHREAD -- DHF

Facility

$821.14

Service Code	HCPCS C1713
Hospital Charge Code	40106999
Hospital Revenue Code	278
Min. Negotiated Rate	$73.90
Max. Negotiated Rate	$410.57
Rate for Payer: Aetna Commercial	$246.34
Rate for Payer: Amerigroup CHIP/Medicaid	$73.90
Rate for Payer: BCBS of TX Blue Advantage	$246.34
Rate for Payer: BCBS of TX Blue Essentials	$295.61
Rate for Payer: BCBS of TX PPO	$328.46
Rate for Payer: Cash Price	$722.60
Rate for Payer: Multiplan Auto	$410.57
Rate for Payer: Multiplan Commercial	$410.57
Rate for Payer: Multiplan Workers Comp	$410.57
Rate for Payer: Scott and White EPO/PPO	$410.57
Rate for Payer: Superior Health Plan EPO	$111.68

ANCH SUT MORPHIX -- DHF

Facility

$4,925.61

Service Code	HCPCS C1713
Hospital Charge Code	40107187
Hospital Revenue Code	278
Min. Negotiated Rate	$1,231.40
Max. Negotiated Rate	$2,462.80
Rate for Payer: Aetna Commercial	$1,477.68
Rate for Payer: Cash Price	$4,334.54
Rate for Payer: Cigna Commercial	$1,231.40
Rate for Payer: Multiplan Auto	$2,462.80
Rate for Payer: Multiplan Commercial	$2,462.80
Rate for Payer: Multiplan Workers Comp	$2,462.80
Rate for Payer: Scott and White EPO/PPO	$2,462.80

ANCH SUT MORPHIX -- DHF

Facility

$4,925.61

Service Code	HCPCS C1713
Hospital Charge Code	40107187
Hospital Revenue Code	278
Min. Negotiated Rate	$443.30
Max. Negotiated Rate	$2,462.80
Rate for Payer: Aetna Commercial	$1,477.68
Rate for Payer: Amerigroup CHIP/Medicaid	$443.30
Rate for Payer: BCBS of TX Blue Advantage	$1,477.68
Rate for Payer: BCBS of TX Blue Essentials	$1,773.22
Rate for Payer: BCBS of TX PPO	$1,970.24
Rate for Payer: Cash Price	$4,334.54
Rate for Payer: Multiplan Auto	$2,462.80
Rate for Payer: Multiplan Commercial	$2,462.80
Rate for Payer: Multiplan Workers Comp	$2,462.80
Rate for Payer: Scott and White EPO/PPO	$2,462.80
Rate for Payer: Superior Health Plan EPO	$669.88

ANCH SUTURE KNOTLESS PUNCH TAC

Facility

$4,132.23

Service Code	HCPCS C1713
Hospital Charge Code	8428502
Hospital Revenue Code	278
Min. Negotiated Rate	$1,033.06
Max. Negotiated Rate	$2,066.11
Rate for Payer: Aetna Commercial	$1,239.67
Rate for Payer: Cash Price	$3,636.36
Rate for Payer: Cigna Commercial	$1,033.06
Rate for Payer: Multiplan Auto	$2,066.11
Rate for Payer: Multiplan Commercial	$2,066.11
Rate for Payer: Multiplan Workers Comp	$2,066.11
Rate for Payer: Scott and White EPO/PPO	$2,066.11

ANCH SUTURE KNOTLESS PUNCH TAC

Facility

$4,132.23

Service Code	HCPCS C1713
Hospital Charge Code	8428502
Hospital Revenue Code	278
Min. Negotiated Rate	$371.90
Max. Negotiated Rate	$2,066.11
Rate for Payer: Aetna Commercial	$1,239.67
Rate for Payer: Amerigroup CHIP/Medicaid	$371.90
Rate for Payer: BCBS of TX Blue Advantage	$1,239.67
Rate for Payer: BCBS of TX Blue Essentials	$1,487.60
Rate for Payer: BCBS of TX PPO	$1,652.89
Rate for Payer: Cash Price	$3,636.36
Rate for Payer: Multiplan Auto	$2,066.11
Rate for Payer: Multiplan Commercial	$2,066.11
Rate for Payer: Multiplan Workers Comp	$2,066.11
Rate for Payer: Scott and White EPO/PPO	$2,066.11
Rate for Payer: Superior Health Plan EPO	$561.98

ANCH SUT Y-KNOT -- DHF

Facility

$3,900.82

Service Code	HCPCS C1713
Hospital Charge Code	40199044
Hospital Revenue Code	278
Min. Negotiated Rate	$351.07
Max. Negotiated Rate	$1,950.41
Rate for Payer: Aetna Commercial	$1,170.25
Rate for Payer: Amerigroup CHIP/Medicaid	$351.07
Rate for Payer: BCBS of TX Blue Advantage	$1,170.25
Rate for Payer: BCBS of TX Blue Essentials	$1,404.30
Rate for Payer: BCBS of TX PPO	$1,560.33
Rate for Payer: Cash Price	$3,432.72
Rate for Payer: Multiplan Auto	$1,950.41
Rate for Payer: Multiplan Commercial	$1,950.41
Rate for Payer: Multiplan Workers Comp	$1,950.41
Rate for Payer: Scott and White EPO/PPO	$1,950.41
Rate for Payer: Superior Health Plan EPO	$530.51

ANCH SUT Y-KNOT -- DHF

Facility

$3,900.82

Service Code	HCPCS C1713
Hospital Charge Code	40199044
Hospital Revenue Code	278
Min. Negotiated Rate	$975.21
Max. Negotiated Rate	$1,950.41
Rate for Payer: Aetna Commercial	$1,170.25
Rate for Payer: Cash Price	$3,432.72
Rate for Payer: Cigna Commercial	$975.21
Rate for Payer: Multiplan Auto	$1,950.41
Rate for Payer: Multiplan Commercial	$1,950.41
Rate for Payer: Multiplan Workers Comp	$1,950.41
Rate for Payer: Scott and White EPO/PPO	$1,950.41

ANCH VERSALOK

Facility

$3,933.73

Service Code	HCPCS C1713
Hospital Charge Code	40107203
Hospital Revenue Code	278
Min. Negotiated Rate	$983.43
Max. Negotiated Rate	$1,966.87
Rate for Payer: Aetna Commercial	$1,180.12
Rate for Payer: Cash Price	$3,461.68
Rate for Payer: Cigna Commercial	$983.43
Rate for Payer: Multiplan Auto	$1,966.87
Rate for Payer: Multiplan Commercial	$1,966.87
Rate for Payer: Multiplan Workers Comp	$1,966.87
Rate for Payer: Scott and White EPO/PPO	$1,966.87

ANCH VERSALOK

Facility

$3,933.73

Service Code	HCPCS C1713
Hospital Charge Code	40107203
Hospital Revenue Code	278
Min. Negotiated Rate	$354.04
Max. Negotiated Rate	$1,966.87
Rate for Payer: Aetna Commercial	$1,180.12
Rate for Payer: Amerigroup CHIP/Medicaid	$354.04
Rate for Payer: BCBS of TX Blue Advantage	$1,180.12
Rate for Payer: BCBS of TX Blue Essentials	$1,416.14
Rate for Payer: BCBS of TX PPO	$1,573.49
Rate for Payer: Cash Price	$3,461.68
Rate for Payer: Multiplan Auto	$1,966.87
Rate for Payer: Multiplan Commercial	$1,966.87
Rate for Payer: Multiplan Workers Comp	$1,966.87
Rate for Payer: Scott and White EPO/PPO	$1,966.87
Rate for Payer: Superior Health Plan EPO	$534.99

ANGINA PECTORIS

Facility

$11,754.70

Service Code	MSDRG 311
Min. Negotiated Rate	$5,426.60
Max. Negotiated Rate	$11,754.70
Rate for Payer: Aetna Commercial	$7,853.62
Rate for Payer: Aetna Medicare	$11,754.70
Rate for Payer: BCBS of TX Blue Advantage	$5,426.60
Rate for Payer: BCBS of TX Blue Essentials	$7,091.22
Rate for Payer: BCBS of TX PPO	$7,879.44
Rate for Payer: Cigna Commercial	$8,991.53

ANGIO EXTREMITY UNILATERAL

Facility

$4,768.00

Service Code	CPT 75710
Hospital Charge Code	2330022
Hospital Revenue Code	323
Rate for Payer: Cash Price	$4,195.84

ANGIO EXTREMITY UNILATERAL

Facility

$4,768.00

Service Code	CPT 75710
Hospital Charge Code	2330022
Hospital Revenue Code	323
Min. Negotiated Rate	$79.96
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$79.96
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$150.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Amerigroup Medicare	$2,915.10
Rate for Payer: BCBS of TX Blue Advantage	$4,572.61
Rate for Payer: BCBS of TX Blue Essentials	$5,487.13
Rate for Payer: BCBS of TX Medicare	$2,915.10
Rate for Payer: BCBS of TX PPO	$6,124.53
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cash Price	$4,195.84
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$150.36
Rate for Payer: Cigna Medicare	$2,915.10
Rate for Payer: Employer Direct Commercial	$2,915.10
Rate for Payer: Humana Medicare/TRICARE	$2,915.10
Rate for Payer: Molina CHIP/Medicaid	$150.36
Rate for Payer: Molina Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Molina Medicare	$2,915.10
Rate for Payer: Multiplan Auto	$3,099.20
Rate for Payer: Multiplan Commercial	$3,099.20
Rate for Payer: Multiplan Workers Comp	$3,099.20
Rate for Payer: Parkland Medicaid	$150.36
Rate for Payer: Scott and White EPO/PPO	$184.44
Rate for Payer: Scott and White Medicare	$2,915.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.36
Rate for Payer: Superior Health Plan EPO	$2,915.10
Rate for Payer: Superior Health Plan Medicare	$2,915.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Universal American Medicare	$2,915.10
Rate for Payer: Wellcare Medicare	$2,915.10
Rate for Payer: Wellmed Medicare	$2,915.10

ANGIO FOLLOW UP EXISTING CATHETER

Facility

$2,387.00

Service Code	CPT 75898
Hospital Charge Code	2320398
Hospital Revenue Code	320
Min. Negotiated Rate	$133.71
Max. Negotiated Rate	$6,603.56
Rate for Payer: Aetna Commercial	$3,254.32
Rate for Payer: Aetna Medicare	$4,372.65
Rate for Payer: Amerigroup CHIP/Medicaid	$133.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Amerigroup Medicare	$2,915.10
Rate for Payer: BCBS of TX Blue Advantage	$1,804.75
Rate for Payer: BCBS of TX Blue Essentials	$2,165.70
Rate for Payer: BCBS of TX Medicare	$2,915.10
Rate for Payer: BCBS of TX PPO	$2,417.28
Rate for Payer: Cash Price	$2,100.56
Rate for Payer: Cash Price	$2,100.56
Rate for Payer: Cash Price	$2,100.56
Rate for Payer: Cigna Commercial	$6,603.56
Rate for Payer: Cigna Medicaid	$133.71
Rate for Payer: Cigna Medicare	$2,915.10
Rate for Payer: Employer Direct Commercial	$2,915.10
Rate for Payer: Humana Medicare/TRICARE	$2,915.10
Rate for Payer: Molina CHIP/Medicaid	$133.71
Rate for Payer: Molina Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Molina Medicare	$2,915.10
Rate for Payer: Multiplan Auto	$1,551.55
Rate for Payer: Multiplan Commercial	$1,551.55
Rate for Payer: Multiplan Workers Comp	$1,551.55
Rate for Payer: Parkland Medicaid	$133.71
Rate for Payer: Scott and White EPO/PPO	$1,193.50
Rate for Payer: Scott and White Medicare	$2,915.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.71
Rate for Payer: Superior Health Plan EPO	$2,915.10
Rate for Payer: Superior Health Plan Medicare	$2,915.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,915.10
Rate for Payer: Universal American Medicare	$2,915.10
Rate for Payer: Wellcare Medicare	$2,915.10
Rate for Payer: Wellmed Medicare	$2,915.10

Know your out-of-pocket cost for care.

All Charges